HCM 11 Fall 2020 Compare & Contrast Paper on Healthcare Systems1 During the first three weeks of class, we discussed a broad overview of the US Healthcare System (chapter 1), its foundational components (chapter 2), and the roles that cost, access and quality play in our healthcare system (chapter 12). We also watched the video entitled, “Sick Around the World”, which is about other healthcare systems and how they compare to the US. Now you are being asked to take a deeper look at the US Healthcare System and compare and contrast it to the healthcare system of either Germany, France or Japan. Instructions Paper criteria includes/answers the following: 1) An introductory paragraph that presents the topic of the paper and gives a brief overview/outline of what will be discussed in the following paragraphs. 2) What are some benefits and limitations of the United States’ healthcare system? 3) What are some benefits and limitations of the other country’s healthcare system? 4) Is the overall health of the other country's population better or worse compared to the United States? o Benchmarks can be used, such as: infant mortality rates, mortality rates for cardiovascular disease, life expectancy for males and females, percentage of people with normal body mass, etc. 5) What are some solutions you would like to see implemented in the U.S. health care system that might improve it? 6) A conclusion paragraph that summarizes the main findings of the paper. 7) A separate APA style reference page and APA in text citations Your paper is due the 9th Week of class (see course outline for exact date). For each day a paper is late, I will take 2 points off the paper grade. Formatting Instructions:      The final paper length must be between 800-1,200 words, not including your reference page You are not allowed to use direct word-for-word quotations from a source. All writing must be in your own words. Double space your work and use 12-point Times New Roman font, one-inch margins You must submit your work as a Word document or PDF. o You have access to Microsoft Office through your Microsoft 365 account that is part of being a student at BCC. I will not be able to open nor grade papers in “.pages, .rtf, or google docs” formats nor will I accept assignments that are submitted in the comments and/text sections of the submission tab. o If you submit your work in an unacceptable format, I will not accept your work and I will consider it as an assignment that has not been submitted yet. I will not accept work that is emailed to me; everything must be submitted via Blackboard. If you have questions about how to use Blackboard visit this website for BCC students: https://site.bcc.cuny.edu/blackboard/?p=bbInstructional-Videos-and-Docs-Students~1#degTop Sources  1 Include at least 4 sources in your paper, with 1 of those being from a peer-reviewed article. Please review the definition of a peer-reviewed article at this website: https://www.angelo.edu/services/library/handouts/peerrev.php before conducting your research. The other sources must be from reputable websites such as newspapers (ie. NYTimes) news websites, org, .gov or .net. This assignment was adapted from the following source: https://pct.libguides.com/nhs/hth325/your-assignment 1    Use APA in-text citation throughout your paper and complete an APA style separate reference page. Refer to the APA guide at: https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/general_format.html if you need to refresh your knowledge of APA. To find peer reviewed articles and other sources go to BCC's library's website http://www.bcc.cuny.edu/library/. Here you will find easy access to search engines for databases, a link where you can chat with a librarian 24/7, and information on how to get free access to the NYTimes and Wall Street Journal by using your BCC student account information. To find more information that is especially relevant to this assignment, visit this website: https://pct.libguides.com/nhs/hth325/your-assignment. Here you will find information about health policy books and journals, national and internal health statistics websites, and ideas for search terms that will How to Cite Your Work The following sources require citation:    All word-for-word quotations from a source. A phrase or sentence(s) copied directly from another source should be clearly identified with quotation marks and the source of that material clearly cited. Please note that you are not allowed to use word-for-word quotations from a source in this assignment. Paraphrasing (putting the ideas of others into “your own words”) It is hard to tell how different your version has to be from the original to make it yours. Rather than trying to make a few changes in what someone else has written (which is plagiarism), describe the important information or ideas in your own words. Be sure, however, to give credit to the source of that information. All in text-citations should be formatted according to APA style. The rule of thumb is that any information included in your assignment that is from another resource should be accompanied with an in-text citation, and an APA style reference should be provided in your separate reference page at the end of the paper. Plagiarism Policy    Please note that I will be using the tool “Turn it In” before I grade your assignment to check for plagiarism. Please also note that academic dishonesty is a serious offense and will be treated as such. While you are tasked to perform a literature/ internet review in this assignment, it does not mean that you can COPY & PASTE sentences/phrases directly from a webpage source. Nor does it mean you can take a sentence from a source and change a few words around and consider it your own. If you do either of these two actions, that constitutes plagiarism. Plagiarism is a form of academic dishonesty and is a serious offense and therefore will be treated as such. Any information you retrieve through your research must be presented in its context but should be written in your own words and given appropriate acknowledgment through in-text citations and listing in the reference section of the assignment. All work submitted by students must be original work. Any attempt to pass someone else’s work (including another student’s work) off as your own will be penalized and action will be taken. If you have any questions about plagiarism and academic honesty, I strongly recommend that you consult me. For more information on CUNY’s policies on academic dishonesty, see the BCC Catalog, pp. 81-82, http://www.bcc.cuny.edu/wp-content/uploads/2018/10/college-catalog-2018-20191.pdf 2 Rubric for Compare & Contrast Paper on Healthcare Systems CATEGORY Introduction/ Paragraph *10 points ____ Very Good Good Developing *exceptional introduction that grabs interest of reader and states paper topic and provides an outline/overview of what will be discussed in the paper *proficient introduction that is interesting and states paper topic and provides an outline/overview of what will be discussed in the paper *basic introduction that states paper topic but lacks interest and may include an some of the outline/overview for the topics that will be discussed in the paper *weak or no introduction of topic. **paper’s purpose is unclear/and there may not be some or no an outline or a clear outline for the paper. Quality of Information/ Evidence *15 points ____ *paper is exceptionally researched, extremely detailed, and accurate. **information clearly relates to the topic of the paper. *information relates to the main topic. **paper is well-researched in detail and from a variety of sources. *information relates to the main topic, few details and/or examples are given. **shows a limited variety of sources. *information has little or nothing to do with the main topic of the paper. **information has weak or no connection to the topic. Quality of Analysis *15 points ____ *exceptionally critical, relevant and consistent connections made between evidence (the sources) and the main points in the paper. **excellent analysis. *consistent connections made between evidence and the main points in the paper **good analysis. *some connections made between evidence and the main points in the paper. **some analysis. *limited or no connections made between evidence and the main points in the paper. **lack of analysis. Organization/ Development of Main Points * 15 points ____ *exceptionally clear, logical, mature, and thorough development of the main points in the paper with excellent transitions between and within paragraphs. *clear and logical order that supports the main points of the paper with good transitions between and within paragraphs. *somewhat clear and logical development with basic transitions between and within paragraphs. *lacks development of ideas with weak or no transitions between and within paragraphs. Conclusion * 10 points ____ *excellent summary of topic with concluding ideas that impact reader. **introduces no new information. *good summary of topic with clear concluding ideas. **introduces no new information. *basic summary of topic with some final concluding ideas. **introduces no new information. *lack of summary of topic. Grammar/Usage/ Mechanics * 10 points ____ *control of grammar, usage, and mechanics. **almost entirely free of spelling, punctuation, and grammatical errors. *may contain few spelling, punctuation, and grammar errors. *contains several spelling, punctuation, and grammar errors which detract from the paper’s readability. *so many spelling, punctuation, and grammar errors that the paper cannot be understood. In-Text Citation Format * 5 points ____ *conforms to APA rules for formatting and citation of sources are perfect. *conforms to APA rules for formatting and citation of sources with minor exceptions. *frequent errors in APA format. *lack of APA format/numerous errors. Reference Page * 10 points *entries entirely correct as to APA format. * Includes at least 4 reputable sources, with 1 of those being from a peer-reviewed article. *entries mostly correct as to APA format. * Includes at least 4 reputable sources, with 1 of those being from a peer-reviewed article. *frequent errors in APA format. May not include 4 reputable sources, with 1 of those being from a peerreviewed article. *lack of APA format/numerous errors. May not include 4 reputable sources, with 1 of those being from a peer-reviewed article. * Follows all the formatting guidelines including paper length Mostly follows all of the formatting guidelines. Follows some of the formatting guidelines Follows few or none of the paper guidelines. ____ Formatting Instructions * 10 points Excellent Total * 100 points 3 3 The health care system in Germany Christian Aspalter Copyright © 2011. Taylor & Francis Group. All rights reserved. Historical development of the public health care system The German public health care system has the world’s longest history. The first compulsory health insurance system in Germany was introduced in 1849 in Prussia; it was compulsory for minors and allowed local communities to oblige employees and their employers to pay financial contributions. In 1881, the Emperor declared social welfare for the poor to be essential for national survival in a hostile world. As a result, the first national health insurance system was introduced by Otto von Bismarck (the Chancellor and head of the government) in the year 1883. The rising power of the working and middle classes caused a lot of worries for the government, which sought to undermine the opposition to its rule by introducing a separate string of health insurance for salaried employees in 1901. After World War II, the old health care system of the Weimar period was reinstalled in West Germany, with sickness contributions now equally shared between employees and employers, and so was its representation (see, for example, Aspalter, 2001; Altenstetter, 2004). The starting point of the reform of the German health care system was in 1977, with the introduction of the Health Insurance Cost-Containment Act, which aimed at putting an end to the rapid increase of health care costs in statutory health insurance of the postwar period, with particular emphasis on cost containment in the hospital sector. A round table for rival corporate organizations was set up to decide on how to cooperate on containing costs. The cost-containment policy of the late 1970s and 1980s intensified after German unification in 1990 (Dixon and Mossialos, 2002; Busse, 2002; EOHCS, 2000; Powell and Wessen, 1999). The main policies of cost-containment included: 1 setting up separate budgets for health care sectors and individual health care providers; 2 the introduction of reference-price setting for pharmaceutical products; 3 implementing restrictions on high-cost technology equipment and the number of ambulatory care physicians per geographic planning region; 4 increasing importance of co-payments for consumers/patients with reference to coverage and level of co-payments; and 5 excluding young people from certain dental benefits from 1997 to 1998. Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. Copyright © 2011. Taylor & Francis Group. All rights reserved. 36 Christian Aspalter The 1990s were a period of intensified health care reform with important pieces of legislation in health care reform: the Health Care Structure Act (1992), the Health Insurance Contribution Rate Exoneration Act (1996), and First and Second Statutory Health Insurance Restructuring Acts (1997), the Act to Strengthen Solidarity in Statutory Health Insurance (1998), and the Reform Act of Statutory Health Insurance (1999/2000) (Busse, 2002; Green and Irvine, 2001; Giamo and Manow, 1999; Powell and Wessen, 1999; Ham, 1997). The 1992 Health Care Structure Act introduced legally fixed budgets or spending caps for the major health care sectors, and case fees and procedure fees in hospital care. It allowed for the first time ambulatory surgery in hospitals, loosening the strict separation between the ambulatory and hospital sectors. In addition, the Act introduced a positive list of pharmaceuticals, which was later abolished, and increased co-payments for ambulatory health care, and restrictions for opening new practices in ambulatory care. Also, a new risk compensation scheme was introduced to redistribute contributions among health insurance funds and to prevent “cream-skimming” by sickness funds (i.e., preferring low-risk insured persons over high-risk insured persons) by means of different risk (and age) structures for insured persons across different health insurance funds. The new risk compensation mechanism was based on individual morbidity profiles of insured persons in each health insurance fund. The most vital change of all that came with the 1992 legislation was the new freedom to choose a health insurance fund for almost all of the insured population. The new laws of 1996 and 1997 signaled a shift from cost-containment policy to a possible extension of private payments in health care financing. Budgets for ambulatory care were abolished, and so the spending caps for pharmaceuticals. Increased co-payments were used across the board to increase the flow of money into the public health care system. New co-payments were introduced for pharmaceuticals, inpatient care, rehabilitative care, medical aids, and transportation to hospitals. Young people from now on had to pay for crowns and dentures by themselves, and a new annual flat premium of c. €10 for the restoration and repair of hospitals – to be paid by the insured – had been introduced. With ascent of the Social Democratic government, the 1998 Act to Strengthen Solidarity in Statutory Health Insurance reversed almost all of these changes, since the new government believed that they would run counter to the main principles of the German health insurance system – that is, uniform availability of benefits, equally shared contributions between employers and employees, financing depending only on income and not on risk or service utilization, and the provision of services as in-kind benefits. The 2000 Reform Act of Statutory Health Insurance aimed at strengthening the primary care system, further loosening the strict separation between ambulatory and inpatient care services, strengthening health technology assessment and quality assurance, and strengthening of patients’ rights. In 2004, hospitals also started to deliver certain highly specialized services on an outpatient basis. The 2007 health care reform set out to increase competition between public health insurance institutions, by way of new incentives within the pharmaceutical pricing and reimbursement policy. In addition, Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 37 the 2007 reform introduced health insurance coverage for all (either public or private), a reform of care structures and health insurance fund reorganization, a reform of private health insurance, and the establishment of the Health Fund to sustain health care financing, with which came a standardized contribution rate for all contributors (BMG, 2009; Nasser and Sawicki, 2009; Busse, 2008; Dixon and Mossialos, 2002; Felder, 2002; Powell and Wessen, 1999). The public health care system today Germany’s health care system is among the middle field when looking at the performance health care systems with regard to life expectancy and death ratios. German citizens’ life expectancy at birth and at age 60 is lower than, for example, those of France and Sweden. The healthy life expectancy of German men is lower than their counterparts in France and Sweden, whereas that of German women is comparable to women in France and Sweden (see Table 3.1 and Box 3.1). Table 3.1 Comparison of health care indicators in Germany, Sweden, the Netherlands, Austria, and Switzerland Copyright © 2011. Taylor & Francis Group. All rights reserved. Germany Sweden Netherlands Austria Switzerland Life expectancy at birth (years) 80 81 80 80 82 Healthy life expectancy at birth (years) 73 74 73 72 75 Infant mortality rate per 1,000 live births 4 2 4 4 4 Adult mortality rate per 1,000 population 78 62 68 75 60 4 3 6 4 5 Doctors per 10,000 population 35 36 39 38 40 Nurses and midwifery personnel per 10,000 population 80 116 151 66 110 Hospital beds per 10,000 population 83 21 48 78 55 Total expenditure on health (percentage of GDP) 10.4 9.1 8.9 10.1 10.8 General governent expenditure on health (percentage of total) 76.9 81.7 82.0 76.4 59.3 3,588 3,323 3,509 3,763 4,417 Maternity mortality rate per 100,000 live births Per capita expenditure on health (PPP, US$) Sources: WHO (2010) and OECD (2009). Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. 38 Christian Aspalter Box 3.1 The health care system in Germany: a summary Copyright © 2011. Taylor & Francis Group. All rights reserved. The German health care system is predominantly funded by contributions that are raised by sickness funds. The power relations between the state and the health care agencies in Germany are based on minimal public control in Germany, especially with regard to individual cases and detailed, strategic health care planning. Germany’s attempts to establish national good practice founded on evidence-based medicine are at a much more rudimentary stage. Germany faces a severe, chronic cost-explosion in the public health care sector due to multiple layers of administration and decision-making, partial over-supply (e.g., provision of ineffective services, empty hospital beds), and over-demand (e.g., a too high average frequency in visits to GPs) for services. In Germany, the government sticks to the principle of social insurance, whereby contributions are based on income levels, and dependants are covered without any surcharge, which is in line with the conviction of the German government that health care is a public good, and that private health care provision is to serve as a complementary, rather than an alternative, source of health care provision. The German government is still struggling to intervene in and regulate the health care market, since powerful interest groups – especially physicians’ organizations, Länder governments, health insurance funds, and the like – are blocking national health care reforms led by the Ministry of Health. Health care expenditure per capita in Germany (US$3,588 at purchasing power parity) is higher than in the Netherlands ($3,509), Sweden ($3,323), and the UK ($2,992), but lower than in France ($3,709), Austria ($3,763), Switzerland ($4,417), or Luxembourg ($5,734). Total health care expenditure in Germany is above EU(15) average (with 9.1 and 10.4 percent of gross domestic product respectively). In comparison, total health care spending in the USA is about 50 percent higher than in Germany – although life expectancy and healthy life expectancy indicators show that people in Germany live longer than in the USA and are healthier, too. Total life expectancy in Germany is 80 years and in the USA 78 years; healthy life expectancy is 73 and 70 respectively. The number of physicians in Germany is 35 per 10,000 inhabitants, and the number of hospital beds is 83. In direct comparison with Sweden, Germany has about the same number of doctors, but four times more hospital beds (Sweden has 36 doctors and 21 hospital beds per 10,0000 population). However, when compared with its direct neighbors the Netherlands and Austria, Germany spends Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 39 about the same amount of money per capita on health care and achieves about the same health care outcomes (UN, 2002; WB, 2002; WHO, 2003, 2010). Germany’s health care system is predominantly (66.4 percent) financed through statutory insurance contributions (56.1 percent from health insurance, 7 percent from long-term care insurance, 1.7 percent from accident insurance, 1.6 percent from retirement insurance), as well as 8.4 percent from national taxation. In 1998 11 percent was financed by out-of-pocket payments and 7.7 percent by private health insurance. In 2009, there were about 220 statutory (public) health insurance funds, the number of which is declining (down from 453 in 1999), since health insurance funds now have the option of merging across different categories (Dixon and Mossialos, 2002; Busse, 2002). Operation of the public health care system At national level, the Federal Ministry for Health and the parliament (the Lower House – the Bundestag – and the Upper House – the Bundesrat) hold the key powers in steering national health policy. However, as regards statutory health insurance, it is the Länder, the federal states, that are primarily responsible for health administration, and, of course, local health policy (see Dixon and Mossialos, 2002; Green and Irvine, 2001). The Federal Ministry of Health is divided into five divisions and two subdivisions each: Copyright © 2011. Taylor & Francis Group. All rights reserved. 1 2 3 4 5 administration and international relations; pharmaceuticals/medical products and long-term care; health care and statutory health insurance; protecting health and fighting disease; consumer protection (mainly food-related) and veterinary medicine. Before the year 1991, some subdivisions were part of other ministries: the statutory health insurance subdivision was part of the Federal Ministry of Labor and Social Services, while most of the other subdivisions were part of the Federal Ministry for Youth, Family, Women and Health. The subdivision for long-term care was transferred only in 1998 from the Ministry of Labor and Social Services. The new structure of responsibility unifies the national administration for health care and health services (see Powell and Wessen, 1999; EOHCS, 2000; Busse, 2002; Dixon and Mossialos, 2002). The Federal Ministry of Health is being assisted by a number of subordinate health authorities, conducting scientific consultancy work and performing certain specific tasks: 1 the Federal Institute for Pharmaceuticals and Medical Devices (BfArM), the major licensing body for pharmaceuticals and supervision of safety of pharmaceuticals and medical devices; 2 the German Institute for Medical Documentation and Information (DIMDI), which provides public and professional information in all fields of life sciences and social sciences; Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. 40 Christian Aspalter Copyright © 2011. Taylor & Francis Group. All rights reserved. 3 the Robert-Koch-Institute, which is a federal institute for communicable and non-communicable diseases, exercising the function of surveillance, detection, prevention, and control of diseases; 4 the Paul-Ehrlich-Institute, a federal institute for the licensing of sera and vaccines; 5 the Federal Center for Health Education (BZgA), which has the task of maintaining and promoting public health; 6 the Federal Institute for Health Protection of Consumers and Veterinary Medicine (BgVV), which controls the protection of consumers’ health in the areas of food, chemicals, cosmetics, veterinary pharmaceuticals and diseases, crop protection and pest control; it also controls the licensing of veterinary pharmaceuticals. The political system of Germany implies application of the principle of subsidiarity and, hence, the sharing of power and decision-making capacities between the federal government and state governments on the one hand, and government authorities and non-governmental corporate bodies on the other (see Bode, 2003; Aspalter, 2001; Altenstetter, 2004). The German Constitution (the Basic Law) distinguishes between areas of exclusive federal legislation and areas of so-called concurrent legislation, for which the Länder are mainly in charge of legislation – however, should there be a piece of federal legislation in this areas, it takes precedence over Länder legislation. For instance, public health, social benefits, public disease control/public safety, certification of pharmaceuticals, drugs, physicians, and other health professionals, and the economic situation of hospitals are not areas of exclusive federal legislation. Implicitly, all other aspects of public health affairs are therefore the responsibility of the Länder. Both the Federal Ministry of Health and the respective state ministries are putting forward proposals for health reform acts at federal and state level. The German system of health care is based on a multi-layer corporatist model of health care administration, with a joint supervision of federal and state ministries in the area of physicians’ associations and health insurance funds, as well as regional and federal hospital organizations. Federal and state ministries are jointly responsible for the supervision of health insurance funds, physicians’ associations, and hospitals (country-wide health insurance funds, federal physicians’ associations, and federal hospital organizations are supervised by the Federal Ministry; regional funds, associations, and organizations are supervised by state ministries) (see Dixon and Mossialos, 2002). The corporatist system in German health care represents itself as a “bipartite” (or “quasi-tripartite”) system, with physicians’ and dentists’ legal associations on the provider side and the health insurance funds and their associations on the purchasers’ side. Health insurance funds need to lead negotiations with physicians about the catalog of available services and the relative point value of services. Also, health insurance funds have to lead negotiations with hospital organizations (which are private, not legally but by ownership) about the catalog of case and procedure fees. Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. Copyright © 2011. Taylor & Francis Group. All rights reserved. The health care system in Germany 41 In every federal state (Land) there are physicians’ associations (every Land has one, except North Rhine-Westphalia, which has two, and Rhineland-Palatinate and Baden-Württemberg, which have four each). In total, 23 organizations represent physicians on the state level; in addition to which there is also one very powerful Federal Association of Statutory Health Insurance Physicians (based in Cologne). Dentists are recognized in the same way as physicians, but their associations are not as powerful as those for physicians. In mid-1999, there were 453 statutory health insurance funds, with about 72 million insured persons (i.e., 50.7 million members plus their dependants). There were 359 company-based health insurance funds (Bebriebskrankenkassen), 42 guild funds (Innungskrankenkassen), 20 farmers’ funds (Landwirtschaftliche Krankenkassen), 17 general regional funds (Allgemeine Ortskrankenkassen), 13 substitute funds (Ersatzkrankenkassen), one miners’ fund (Krankenkasse der Bundesknappschaft), and one sailors’ fund (See-Krankenkasse). Since the mid-1990s there has been a wave of mergers of health insurance funds, to save costs and to become more attractive for consumers, and competitive in the new market place of health insurance funds (after introducing the freedom of choice for membership in health insurance funds) (Dixon and Mossialos, 2002; Busse, 2002; Green and Irvine, 2001). In most funds, the management is made up of an executive board that is responsible for the day-to-day management of the fund and, in addition to that, an assembly of delegates deciding on bylaws and other regulations of the fund, passing the budget, setting the contribution rate of the health insurance fund, and electing the executive board. In general, the assembly is composed of representatives of the insured and the employers (only in substitute funds do representatives exclusively represent the insured); all representatives are democratically elected every six years, and many representatives are linked to employers’ associations and trade unions. The hospitals are represented not by any legal corporate institution but by organizations based on private law; they are, however, also increasingly charged with legal responsibilities (e.g., in the Federal Joint Committee, see Nasser and Sawicki, 2009); there are Länder organizations, as well as a federal organization in Düsseldorf. In Germany today, patients have the freedom to choose (the most efficient or suitable) health insurance funds, as well as to choose hospitals and physicians on their own. Health insurance funds have the obligation to contract patients; physicians and hospitals have the duty to treat all patients (see Dixon and Mossialos, 2002; Green and Irvine, 2001; EOHCS, 2000). Financing of the public health care system Health insurance contributions make up the lion’s share of the financing of Germany’s health care system. Hence, the present financing system basically is a tax on labor. It exercises negative distortions on labor and production markets, leading to high, long-term unemployment. The more one works, and the Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. Copyright © 2011. Taylor & Francis Group. All rights reserved. 42 Christian Aspalter higher one’s salary is, the higher are the premiums for the members of the health insurance funds; the services offered do not change with increased work levels or performance (they vary, however, between different health insurance funds that represent different income strata, e.g., members of general health insurance funds and members of health insurance funds catering to white-collar employees). There is a strong mechanism of redistribution between high-income and lowincome earners, and also between people who have dependants (especially those who have more dependants) and those who do not (working women, unmarried persons, persons without children). German health insurance funds are required to be financially self-sufficient; premiums are set as a percentage of insured person’s income, with employer and employee paying half each. In 2008, the average insured employee contributed almost 8 percent of gross wage, while the employer added another 7 percent (Busse, 2008). People with less than €325 per month income are not liable for health insurance fund contributions; instead, employers have to contribute a fixed rate of 10 percent for all funds. In the cases of retired and unemployed persons, the retirement and unemployment funds respectively take over the financing role of the employer. The “public”–“private” mix in health care financing reveals a ratio of 3:1. The “public” share in 1998 was 74.8 percent, with public budgets 8.4 percent, statutory health insurance 56.1 percent, statutory long-term care insurance 7 percent, statutory accident insurance 1.7 percent, and statutory retirement insurance 1.6 percent. The “private” share in 1998 was 25.2 percent; with 11 percent from out-of-pocket payments, 7.7 percent from private health insurance, 4.3 percent from employers, and 2.4 percent from private organizations. The overall public share rose and equaled 76.9 percent in 2006. Within the private share, the percentage of financial contribution from private health insurance rose to about 9.1 percent of total health care expenditure in the previous year. For 2006, public health insurance contributed 57 percent of overall health expenditure. The public long-term care insurance, accident insurance, and pension insurance systems contributed another 7.4, 1.7, and 1.5 percent respectively. Private health insurances covered 4.2 percent of total expenditure, the private sector (mostly nongovernmental organizations) 33.3 percent, and co-payments another 5.5 percent (see Schmitz, 2009; Busse, 2002, 2008; Riesberg and Busse, 2003; Dixon and Mossialos, 2002). Since members were traditionally assigned to join their respective health insurance funds based on geographical and/or job characteristics, the contribution rates in the past also varied greatly between different funds, owing to different income levels and health risk profiles that were prevalent among their particular groups of members. To fulfill the mandate of equal health standards across all of Germany, which was set down in the German Constitution, a new risk compensation scheme was set up in 1994 and 1995 to equalize differences resulting from varying contribution rates (as a result of different income levels) and from expenditure patterns (as a result of the particular age and sex composition of health insurance members). The new risk compensation scheme, indeed, narrowed contribution rates between funds. The new freedom of the insured to choose health insurance funds Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 43 led to a hiving off of younger, healthier, better-earning people, who have chosen to join cheaper funds (with lower contribution rates), and this fact has increased transfer sums between health insurance funds. Thus, the new risk compensation scheme is needed, now more than ever before, as a permanent institution that ensures the working of the German health insurance system. Without the new risk compensation scheme, a race to the bottom might have been expected, as people would flee more and more toward discount insurance funds. The compensation scheme makes cheaper funds possible, but the emergence of discount schemes is still impossible, since statutory health insurance funds for the younger, healthier, and wealthier have to compensate those funds that cater to older, less healthy, and less wealthy populations (see Green and Irvine, 2001; EOHCS, 2000). In July 2009, the unified contribution rate was lowered to amount to 14.9 percent of payroll; 7.9 percent employee contributions and 7 percent employer contributions (Braun, 2009). Copyright © 2011. Taylor & Francis Group. All rights reserved. Benefits in the public health care system Germany’s dual health insurance system is based on private and statutory (notfor-profit, governed by law) insurance institutions. Membership in statutory health insurance schemes comprises both mandatory and voluntary members. A total of 88 percent of the population are covered by statutory health insurance: 74 percent are mandatory members or their dependants, 14 percent are voluntary members or their dependants. Some 2 percent of people enjoy free governmental health care – these are police officers, soldiers and those doing the civil alternative to military service, and people on social welfare) – and fewer than 0.2 percent are not insured (see Dixon and Mossialos, 2002; Busse, 2002). Social legislation (the Social Code Book) requires that citizens who pursue gainful employment, plus other particularly defined groups – pensioners, farmers, students, artists, the disabled, and the unemployed – have to contract a statutory health insurance scheme. Permanent civil servants and soldiers, as well as a few others (e.g., people working for the European Commission) are, however, exempted from this rule. In addition to that, employees with a salary above a designated threshold are also exempted from the rule of mandatory membership; this threshold is usually adjusted annually to match the increase in inflation. As a result of the threshold, some groups of gainfully employed people may opt out of the statutory system. These are: (a) employees whose income exceeds the income threshold for compulsory insurance from the start of their first gainful employment (or up to two months after returning from another country); (b) employees who left the statutory scheme but are brought back within the scope of compulsory insurance by an increase in the threshold or a reduction in their weekly working hours if they have been outside the statutory scheme for at least five years (now the rule applies only to persons over 55 years of age); and (c) certain other groups that can opt out and be – irrevocably – exempted from mandatory membership (e.g., young physicians, who in the first 18 months earn far below the threshold). Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. Copyright © 2011. Taylor & Francis Group. All rights reserved. 44 Christian Aspalter On the other hand, voluntary membership in the statutory health insurance scheme is allowed to (a) employees whose income exceeds the earnings threshold (€48,000 yearly income) from the start of their first gainful employment if they apply within three months, and (b) employees whose earnings are initially below the threshold but then exceed the threshold as a result of pay increases, who may remain in the statutory scheme as voluntary members if they have been statutory health insurance members for the last 12 months, or for 24 months within the last 60. Therefore, people with private health insurance coverage are (a) those who were formerly insured, but opted out of the system once they reached the threshold, (b) those who are self-employed – they are excluded from statutory membership unless they were previously members (self-employed farmers are required to join statutory insurance schemes on a mandatory basis) – and (c) active and retired permanent public employees, such as teachers, university professors, and employees in ministries (the government reimburses most of their private health care bills; they need private insurance to cover only the remainder). Less than 1 percent of the population is not covered by any health insurance. Beginning in 2009, health insurance is mandatory, depending on previous insurance and/or job status, in either the social or a private health insurance scheme (see EOHCS, 2000; Green and Irvine, 2001; Dixon and Mossialos, 2002; Busse, 2002, 2008). In the German health care system, benefits are more clearly defined than in the United Kingdom. Benefits are defined on two separate levels: first, by law and, second, through delegated decision-making. The Social Code Book (Sozialgesetzbuch) depicts, for the most part in generic terms, the following types of benefits that must be included in the benefit package: (a) prevention of disease, (b) screening of disease, (c) treatment of disease (ambulatory medical care, nonphysical care, dental care, medical devices, inpatient/hospital care, nursing care at home, and certain areas of rehabilitative care), (d) transportation to and in between hospitals, and (e) statutory social insurance funds need to pay cash benefits – 80 percent of pay (for up to 78 weeks) – to members after the first six weeks of their sickness (during the first six weeks of sickness employers need to pay 100 percent of employees’ income in sick pay) (EOHCS, 2000; Green and Irvine, 2001; Dixon and Mossialos, 2002; Busse, 2002, 2008). The Social Code Book regulates, in great detail, health care benefits in the areas of prevention and screening – apart from that, benefits are defined in rather generic terms. On the second level of decision-making (the corporate level), further benefit regulations are decided by the Federal Association of Physicians and Health Insurance Funds (Bundesausschuss der Ärzte und Krankenkassen). The Association has considerable leverage in determining benefit packages with regard to ambulatory, curative, diagnostic, and therapeutic procedures. The range of procedures is wide, covering from basic physical examinations in physicians’ surgeries, home visits, and antenatal care to care for terminally ill patients, surgical procedures, laboratory tests, and imaging procedures including magnetic resonance imaging. The Social Code Book gives a detailed description of dental, especially prosthetic, benefits. One reason for this is the weaker role of the Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 45 Federal Association of Dentists and Health Insurance Funds (Bundesausschuss der Zahnärzte und Krankenkassen) in Germany’s corporatist health care system. The non-physician care sector comprises personal medical services of professionals other than physicians – that is, physiotherapists, speech therapists, and occupational therapists. German citizens are entitled to such services unless any are explicitly excluded by the Federal Ministry of Health (currently not the case). However, non-physician services may be delivered to the insured only if their therapeutic efficiency is recognized by the Federal Association of Physicians and Health Insurance Funds. The range of services provided in the hospital sector is determined also on two levels: first, the Länder government (in their hospital plan) and, second, negotiations between the health insurance funds and each individual hospital (hospitals are not a corporatist body and, hence, do not have a collective body that may negotiate over benefits provided and their remuneration) (see EOHCS, 2000; Green and Irvine, 2001; Dixon and Mossialos, 2002; Busse, 2002, 2008). Copyright © 2011. Taylor & Francis Group. All rights reserved. Remuneration for doctors and financing of hospitals, medical facilities, and goods The scope of benefits that doctors receive from health insurance funds is determined in joint negotiations between health insurance funds and physicians. The top level of joint negotiation is held within the national-level Federal Committee of Physicians and Health Insurance Funds, which consists of nine representatives from both sides (usually chairpersons from the various associations), two neutral members with one proposed by each side, and a neutral chairperson who must be accepted by both sides and who has the decisive vote if no agreement can be reached. In July 1997, the Committee received new competencies as laid down in the Second Statutory Health Insurance Restructuring Act. In addition to guidelines for steering the behavior of all office-based physicians and needs-based planning guidelines (which provide the actual framework for planning at Länder level through Länder Committees), the Federal Committee now is also responsible for technology assessment of the existing catalog of ambulatory benefits, for defining a positive list for care by non-physicians, and for guidelines defining rehabilitative entitlements (see Busse, 2002; Dixon and Mossialos, 2002; EOHCS, 2000; Ham, 1997). The Federal Committee has several subcommittees, one of which had made proposals for decisions according to a set of criteria that were outlined in guidelines first passed in 1990. After the extension of the Federal Committee’s mandate, this subcommittee was renamed the Medical Treatment Subcommittee and passed new evaluation guidelines. Another separate joint committee of physicians and sickness fund representatives at federal level, the Valuation Committee, makes decisions on the relative value of all services in the ambulatory part of the benefits catalog – that is, the Uniform Value Scale. The payment system of office-based statutory health Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. Copyright © 2011. Taylor & Francis Group. All rights reserved. 46 Christian Aspalter insurance-affiliated ambulatory physicians follows a two-step process: (1) the sickness funds allocate global budgets to the physicians’ associations, on the basis of a capitation per member or per insured person, and then (2) the physicians’ associations pay their members for the services provided according to the Uniform Value Scale. Each medical procedure is worth a certain point value. Each physicians’ association budget is divided by the total number of service points achieved by its members, and then reimbursed accordingly. Hospitals contract individually with the health insurance funds (which leads to high transaction costs) owing to the absence of any corporatist institution for the hospital sector. Customarily, all health insurance funds with a market share of more than 5 percent in a particular hospital negotiate the contract with that hospital. However, the conditions regarding both the range and number of services offered and the remunerations rates are valid for all health insurance funds (including those not represented at the negotiations) (see Klimenta, 2004; Mossialos and LeGrand, 1999). The 2000 Reform Act of the Statutory Health Insurance introduced a “quasicorporatist” system for hospitals, as they now were allowed (after the ministry unsuccessfully attempted to fully “corporatize” the hospital sector) to negotiate also the catalog of prospective case and procedure fees with the health insurance funds. As a result, a new (quasi-corporatist) institution was created, the Committee for Hospital Care. The Committee for Hospital Care is made up of 19 persons (nine from health insurance funds, five from hospitals, four from the Federal Physicians’ Chamber, and the chairperson of the Federal Committee of Physicians and Health Insurance Funds). Supervision of decisions made within the corporatist realm (either uniform decision-making or decisions by a joint committee) is a multi-layered endeavor that involves not only the corporatist, self-regulatory institutions themselves, but also, and very importantly, the government and the social courts (a special court system that is set up to decide on cases that fall into the scope of social legislation). The government may approve decisions taken by these self-regulatory bodies, override them (if they are not taken according to law), or pose legal threats to institutions that intentionally or unintentionally do not fulfill their prescribed tasks. Health insurance funds are subject to closure mainly in cases of financial instability or incompetence. The ultimate threat to professional associations is that a state commissioner may be installed if no board is elected or if the elected board refuses to act according to its legal responsibilities. In case that 50 percent or more members of a professional association, such as the physicians’ and dentists’ associations, refuses to treat patients who have insurance with a sickness fund, the association loses its legal monopoly on providing ambulatory care, which is then passed to the health insurance funds. The last two threats were introduced only in 1992, after self-governing bodies announced their intention to disobey certain legal requirements. The dual financing system of the German hospital care sector implies that the financing of running costs is the task of statutory health insurance funds (plus private insurers with regard to services received by private patients), and that the Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 47 financing of investment costs for hospitals is fulfilled by the Länder governments, which set up specific hospital plans that cover new investments in hospitals. The licensing of medical devices is the responsibility of authorized institutions, which require accreditation through the Federal Ministry of Health. On top of that, the Medical Device Directive of the European Union applies also in Germany. The newly created Committee for Hospital Care is charged with health technology assessments for technologies used in the hospital sector. Until 1982, when the Hospital Cost-Containment Act came into effect, no regulations concerning medical devices existed. After the introduction of this law, it became mandatory for expensive devices to be subject to hospital planning. Devices that were not part of an agreement could, from then on, not be considered in the per diem charges and thus could not be refinanced. With regard to expensive medical devices in the ambulatory care sector, the 1997 reform abolished the control of joint committees, replacing it with direct control of self-governing corporate bodies, who now have to guarantee the efficient use of expensive equipment through remuneration regulations (this could lead to an even steeper increase in the number of expensive medical devices). The government recently set up new institutions that are to ensure better value in the provision of health care by means of health technology assessment: the German Scientific Working Group Technology Assessment and the German Institute for Medical Documentation and Information (DIMDI), which has the task of establishing a database containing relevant health technology assessment results as well as supporting decision-making processes by the Federal Committee and other actors (see Busse, 2002; Dixon and Mossialos, 2002; Green and Irvine, 2001; EOHCS, 2000). Copyright © 2011. Taylor & Francis Group. All rights reserved. Pharmaceutical products Pharmaceutical care products are provided by community pharmacists, which in Germany are called “public” pharmacists since every pharmacist may own and operate only one pharmacy (i.e., chain pharmacies are illegal). Pharmaceutical expenditures in Germany amount to US$300 per capita per year (in 1998), 20 percent higher than the figure for the UK. There is no public planning of pharmacy locations; however, ownership is restricted to one pharmacy per owner. On the other hand, pharmacies are protected in the way that many pharmaceutical products are classified as “pharmacy-only” and, thus, need to be purchased in pharmacies; a second classification exists for “prescription-only”, which, in addition, also requires a prescription by a general practitioner. In Germany, most pharmaceuticals enjoy free market entry and, thus, may be prescribed and paid for by statutory health insurance funds – with a few very important exceptions: 1 Since 1983, drugs for certain conditions (common colds, drugs for the oral cavity with the exception of antifungals, laxatives, and drugs for motion Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. 48 Christian Aspalter sickness) are excluded from the benefits package for the insured over 18 years of age. 2 The Minister of Health is allowed by the law to exclude “inefficient” drugs – that is, drugs that are not effective (for the desired purpose) or combine more than three drugs whose effect cannot be evaluated with certainty. This also applies to homeopathic, anthroposophic, and phytotherapeutic drugs. A “Blacklist of Drugs” based on these principles came into effect in 1991, was revised in 1993, and contains about 2,200 drugs. 3 Drugs for “trivial” diseases (such as common colds) that can usually be treated with treatments other than drugs may be excluded (a special list of such drugs has not been set up yet). The pharmaceutical sector is one of the traditional areas of cost-sharing in the German health care system. Co-payments are legally defined and range from €5 to €10 per pack, depending on size. On top of that, patients are required to pay any part of the price above the reference price. This, however, hardly ever occurs, as pharmaceutical companies adapt the prices of products to the reference price (see EOHCS, 2000; Dixon and Mossialos, 2002; Busse, 2002, 2008). Copyright © 2011. Taylor & Francis Group. All rights reserved. Complementary and alternative medicine The life-time prevalence of the use of complementary and alternative medicine gradually increased from 30 percent in 1970 to 56 percent in 2002 in West Germany. Both life-time prevalence and one-year prevalence increased in all of Germany between 1997 and 2002 – from 64 to 71 percent in East Germany, and from 51 to 56 percent in West Germany. In Germany in 2001, 15.2 active physicians per 100,000 inhabitants had additional qualifications in chiropractic, 5.2 per 100,000 additional qualifications in homeopathy, and 12.6 per 100,000 additional qualifications in naturopathy. The number of physicians practicing any of these additional qualifications doubled between 1993 and 2001 (in both ambulatory and inpatient care) (see Dixon et al., 2003). Once medical doctors are specialized, they can obtain additional qualifications (Zusatzbezeichnungen) relating to specific complementary and alternative medicine methods (e.g., homeopathy or chiropractic), or to a broader field of naturopathy. Other additional complementary and alternative medicine provisions in physical medicine are “physical therapy,” “balneology and medical climatotherapy,” and “physical and rehabilitation medicine.” Other practitioners include, for example, psychotherapists, psychologists, Heilpraktiker, homeopaths, dieticians, nurses, midwives, masseurs, and medical bath attendants. There is a certain number of non-registered practitioners, most of whom work in the beauty and fitness sector, some in social care, and yet others in education. Complementary and alternative medicine has become part of the standard curriculum of German medical schools, where students are tested on their knowledge of complementary and alternative medical methods. To obtain a complementary and alternative medical license, a physician must prove that he or she has an Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 49 academic degree in medicine, practical experience in this field, a license from public authorities, and a medical certificate confirming that the candidate has no physical or mental illnesses including drug abuse. Over-the-counter sales of complementary and alternative medical products and services have been stagnant recently, owing to the decrease in public reimbursement for herbal medicines, naturopathy and spa treatments – although, here also the public debate, conversely, perceives an increase in the demand for complementary and alternative medicines. Compared with the United Kingdom, Germans use more natural remedies, but consult complementary and alternative practitioners less than their UK counterparts. Osteopathy, reflexology, and aromatherapy are rarely delivered and reimbursed in Germany; by contrast art therapy, anthroposophic therapies, neural therapies, hydrotherapy, and auto-hematotherapy are commonly delivered in Germany, but hardly in the United Kingdom. Whereas in the UK both chiropractic and osteotherapy are recognized for public reimbursement, German health insurance funds reimburse only chiropractic services (Dixon et al., 2003). Copyright © 2011. Taylor & Francis Group. All rights reserved. Health promotion The promotion of public health in national policy-making seems be lacking the overall attention of public authorities and the general public. Only very slowly the Länder set targets for public health (North Rhine-Westphalia started in 1994; others followed in 1997 and thereafter). It becomes clear that priority-setting in this area does not seem to be high on the political agenda. One of the first federal initiatives in public health promotion dates back to 1989, as the Health Care Reform Act mentioned the responsibility of health insurance funds to undertake health promotion activities. As a result of the heightened competition between health insurance funds in 1997, the issue of health promotion gained renewed attention. At the end of 1996, health care targets were the only remaining area in which the benefits’ catalogs differed between funds (see Dixon and Mossialos, 2002; Busse, 2002). Germany’s health care system, by and large, lacks a comprehensive and systematic approach to the prevention of ill health. Learning from the UK experience, Germany’s government has decided to establish a similar system for the improvement of national health standards. Germany has been moving to a new morbiditybased compensation mechanism in the year 2009. A new focus on health care promotion certainly has to include national standards (on top of sporadic cases of state-level standards) that focus on national and regional mortality/life-expectancy rates, and potential years of life lost. Any comprehensive approach in addition has to distinguish between indicators of health of different population groups (e.g., focusing on the distribution across sex, age, and occupation groups as well as regional/local distributions of health outcomes) (see Busse, 2008). Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. 50 Christian Aspalter Copyright © 2011. Taylor & Francis Group. All rights reserved. References Altenstetter, C. (2004), Insights from Health Care in Germany, in C. Harrington, C. Estes, and C. Crawford (eds.), Health Policy: Crisis and Reform in the US Health Care Delivery System, Jones and Bartlett: Sudbury, MA. Aspalter, C. (2001), Importance of Christian and Social Democratic Movements in Welfare Politics: With Special Reference to Germany, Austria and Sweden, Nova Science: New York. BMG (Bundesministerium für Gesundheit) (2009), Health Care System and Health Care Reform in Germany, www.bmg.bund.de. Bode, I. (2003), The Welfare State in Germany: Corporatism and the German Welfare Model, in C. Aspalter (ed.), Welfare Capitalism around the World, Casa Verde: Hong Kong. Braun, M. (2009), German Health Care Reform, www.mercer.com. Busse, R. (2002), Health Care Systems, Deutsch–Britische Stiftung für das Studium der Industriegesellschaft: Berlin. Busse, R. (2008), The German Health Care System, www.commonwealthfund.org. Dixon, A., Riesberg, A., Weinbrenner, S., Saka, O., Le Grand, J., and Busse, R. (2003), Complementary and Alternative Medicine in the UK and Germany: Research and Evidence on Supply and Demand, Deutsch–Britische Stiftung für das Studium der Industriegesellschaft: Berlin. Dixon, A. and Mossialos, E. (eds.) (2002), Health Care Systems in Eight Countries: Trends and Challenges, EOHCS: London. EOHCS (European Observatory on Health Care Systems) (2000), Health Care Systems in Transition: Germany, EOHCS: Copenhagen. Felder, S. (2002), Reform of Germany’s Health Care Market, working paper, Institute of Social Medicine and Health Economics, University of Magdeburg, Germany. Giamo, S. and Manow, P. (1999), Adapting the Welfare State: The Case of Health Care Reform in Britain, Germany and the United States, Comparative Political Studies, Vol. 32, No. 8, pp. 967–1000. Green, D.G. and Irvine, B. (2001), Health Care in France and Germany: Lessons for the UK, Civitas: London. Ham, C. (ed.) (1997), Health Care Reform: Learning from International Experience, Open University Press: Buckingham, UK. Klimenta, H. (2004), Gesundheit ist keine Ware (Health is not a good), ATTAC – Kampagne Soziale Sicherungssysteme, July 2, www.attac.de. Mossialos, E. and LeGrand, J. (eds.) (1999), Health Care and Cost-Containment in the European Union, Ashgate: Aldershot, UK. Nasser, M. and Sawicki, P. (2009), Institute for Quality and Efficiency in Health Care: Germany, www.commonwealthfund.org. OECD (2009), OECD Health at a Glance, OECD: Paris. Powell, F.D. and Wessen, A. (eds.) (1999), Health Care Systems in Transition, Sage: London. Riesberg, A. and Busse, R. (2003), Cost-Shifting (and Modernization) in German Health Care, Euro Observer, Vol. 5, No. 4, pp. 4–5. Schmitz, H. (2009), Health Care in Germany: The Hospital Financing System, www.acss. min-saude.pt. UN (United Nations, Population Division, Department of Economic and Social Affairs) (2002), Population Aging, United Nations: New York. Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. Created from bcc-ebooks on 2020-11-13 18:57:41. The health care system in Germany 51 Copyright © 2011. Taylor & Francis Group. All rights reserved. WB (World Bank) (2002), World Development Indicators, World Bank: Washington, DC. WHO (World Health Organization) (2003), World Health Report, World Health Organization: Geneva. WHO (2010), World Health Statistics 2010, World Health Organization: Geneva. Health Care Systems in Europe and Asia, edited by Christian Aspalter, et al., Taylor & Francis Group, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bcc-ebooks/detail.action?docID=981745. 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